Moving forward: why responding to migration, mobility and HIV in South(ern) Africa is a public health priority

Abstract Introduction Global migration policy discussions are increasingly driven by moral panics – public anxiety about issues thought to threaten the moral standards of society. This includes the development of two Global Compacts – agreed principles to guide an international response – for (1) “Refugees” and (2) “Safe, Regular and Orderly Migration.” While the need to address migration and health is increasingly recognized at the global level, concerns are raised about if this will be reflected in the final Compacts. The Compacts focus on securitization, an approach that aims to restrict the movement of people, presenting potentially negative health consequences for people who move. Globally, concern is raised that migration‐aware public health programming initiatives could be co‐opted through a global health security agenda to further restrict movement across borders. This is particularly worrying in the Southern African Development Community (SADC) – a regional economic community associated with high levels of migration and the largest population of people living with HIV globally; this case is used to explore concerns about the health implications of the Global Compacts. Discussion Current HIV responses in SADC do not adequately engage with the movement of healthcare users within and between countries. This negatively affects existing HIV interventions and has implications for the development of universal HIV testing and treatment (UTT) programmes. Drawing on literature and policy review, and ongoing participant observation in policy processes, I outline how Global Compact processes may undermine HIV prevention efforts in SADC. Conclusions The global health imperative of developing migration‐aware and mobility‐competent health responses must not be undermined by moral panics; the resultant international policy processes run the risk of jeopardizing effective action at the local level. Globally, migration is increasingly recognized as a central public health concern, providing strategic opportunities to strengthen public health responses for all. Without mainstreaming migration, however, health responses will struggle. This is particularly concerning in SADC where HIV programmes – including UTT initiatives – will struggle, and key health targets will not be met. Globally, contextually appropriate migration‐aware responses to health are needed, including and a specific focus on HIV programming in SADC.


| INTRODUCTION
While health has long been considered an essential component of human and economic development, the health of migrants has remained in the shadows of key global health, migration, and development dialogues and processes, and many migrants still lack access to affordable health services. (IOM, 2017: p. 4) In spite of recent calls at the global level to improve responses to migration and health, and the development of a global research agenda to support this [1][2][3][4], the "unfinished agenda of migrant health for the benefit of all" [5,6] remains a glaring gap in current global, regional and national policy discussions. To further complicate this situation, attempts to develop interventions on migration and healthat all levelsmay be undermined by the global migration policy terrain. Following the 2016 "New York Declaration on Refugees and Migrants" [7], two Global Compacts are due to be finalized and released in the second half of 2018the "Global Compact on Refugees, " and the "Global Compact on Safe, Regular and Orderly Migration. " Global Compacts refer "to an agreement between states on matters of common interest of concern, " and provide opportunities for determining how member states will "conduct themselves in the future"in this case in relation to the management of migration [8]. Two discrete motivations for engaging with migration at a global level currently existone from a right to health, wellbeing, and public health perspective [1,3], and the other from a securitization and restriction of movement approach [8,9]. The resulting tensions within the global community present multiple challenges for the development of improved responses to migration and health.
In this commentary, I explore the implications of the current global migration policy terrain for the Southern African Development Community (SADC), a regional economic community made up of 15 member states that is associated with high levels of both internal (within country) and cross-border (between country) migration and a high communicable disease burden, including the largest population of people living with HIV globally [10][11][12][13]. With the aim of offering suggestions for ways to mobilize a regional response to migration and HIV in SADC, I outline the challengesand strategic opportunitiesthat result from the current global migration policy terrain. This is done by drawing on a review of research and policy associated with migration and HIV in SADC (13 and Table 1) and my ongoing participant observation within various global, regional and national policy processes.

| A global policy crisis?
As evidenced by the current Global Compact processes, we find ourselves in a world increasingly concerned with securitizing national borders and restricting the movement of people between nation states. Much of this focus on security is driven by moral panicspublic anxiety about issues thought to threaten the moral standards of societyassociated with migration, including human trafficking and the independent movement of women [9], and the so-called "Migration Crisis" in Europe [14][15][16]. Internationally, discussions on migration tend to ignore long-established population movements within Global South contexts where forced migration and movement in search of improved livelihood opportunities are commonplace and outnumber similar movements in the Global North; the Southern African region is no exception [17]. The current global discourses surrounding population mobilitythat are fuelling morally panicked policy discussionshave negative impacts both for those who move, and for the development of improved responses to migration and health. Centrally, this includes the implementation of increasingly restrictive immigration policies, including further securitization of the borders of nation sates. In relation to health and wellbeing, historical perceptions of the migrant as the "diseased body"; as a carrier and transmitter of infectious diseases, particularly HIV; and, consequently, as a burden on the welfare state of receiving countries, are reemerging [18][19][20][21]. We need to remain vigilant and ensure that the re-emergence of this discourse is not used to support securitization agendas as health status may (once again) be used to mediate the ability to legally cross national borders. Particularly worrying is that this may include an unwelcome return to a focus on the HIV status of people crossing borders.
The "draft zeros" of the two Global Compacts were released in early 2018 [22,23] and, while they do acknowledge health, concerns remain that healthand other social justice issueswill be left off the final agenda [9,24]. As a result, the final Global Compacts run the risk of calling for actions that ignore or may even be in contravention ofexisting approaches aimed at improving health for all, including the Sustainable Development Goals ( Table 1 summarizes the key international policy processes that have been engaging with migration and health, and the more recent processes associated with the Global Compacts. From a review of these processes, participation in both the 1st and 2nd Global Consultations on Migration and Health in 2010 and 2017 [3,28], and more recent engagement in global migration and health research initiatives, it becomes apparent that the progressive agenda being developed around migration and health stands the risk of being undermined by the Global Compacts process. With a clear focus on securitization and the restriction of movement, health-related issues are being side-lined in current global discussions. In addition, and particularly important for SADC, concerns have been raised that the loudest voicesthose associated with the anti-immigrant agendas of northern Europe, are driving the Global Compact processes, resulting in a global agenda calling for further restrictions on international migration which will be detrimental to other regions of the world, including the African continent [29-31]. To this end, the African Union developed a draft Common African Position, that involved regional dialoguesincluding within SADCin an attempt to ensure that the contextual realities of the continent are engaged with in the finalization of the Global Compacts [32]. This Position paperwhich makes reference to the importance of ensuring access to healthcare for migrantswas presented in draft form at the international preparatory meeting on the Global Compacts held in Mexico in December 2017, and has since been finalized and approved [33]. How effective these interventions are, and whether health-related concerns are emphasized in the final Compacts, remains to be seen.

| Migration, mobility and HIV
In spite of the SADC region being associated with a long history of diverse population movements, current public health responses to HIV still fail to adequately engage with migration and the movement of healthcare usersboth within and between countries [10][11][12]. The result is a range of negative outcomes with serious implications for population health and HIV prevention, including challenges in initiating treatment, ensuring treatment continuity, and the associated risks for defaulting and drug resistance [34]. In addition, the absence of evidence-informed and migration-aware responses to HIV has led to the continued scapegoating of migrantsparticularly non-nationalsas the carriers of HIV; the "diseased" migrant body is a long-standing trope, and one that conjures up the idea of the migrant as a disease vector, whose movements are solely responsible for the spread of new HIV infections [18]. Such imaginings conveniently absolve the state from its own shortcomings in terms of inadequate healthcare, health promotion and HIV prevention strategies. Rather, the state and their healthcare institutions blame internal and cross-border movements for placing an excessive burden on the state.
Globallyand in SADCkey population groups currently targeted for HIV prevention initiatives are often highly mobile, including sex workers and men who have sex with men [13]. Recent UNAIDS Gap Reports make the case for developing migration-aware responses to HIV, acknowledging the importance of developing cross-border initiatives and mainstreaming migration into national HIV strategic plans [13,[35][36][37]]. This has implications for the development and implementation of effective HIV prevention programming, including universal HIV testing and treatment (UTT) and pre-exposure prophylaxis (PreP). A key challenge relates to how to do this: migration is a politically sensitive issueassociated with anti-foreigner and xenophobic rhetoric, in spite of internal mobility being far Table 1. An overview of key global and regional migration and health policy processes (expanded on from [3,12] more prevalent-and HIV (and health more broadly) is also a politically sensitive concern. Bringing together the interconnected concerns and agendas relating to migration and HIV is challenging and innovative approaches to this are required; migration is a central public health concern thatif approached carefullycan provide a strategic opportunity to strengthen responses to HIV for the benefit of all. For example, framing the development of responses to migration and HIV as a key entry point to improving health for all, for addressing health inequities, and for working towards universal health coverage, could assist in obtaining the political support needed to fund and support migration-aware responses to HIV in SADC. This will have further positive impacts, namely in supporting activities for achieving global health targets, including the SDGs [26] and the UNAIDS 90-90-90 targets [38]. However, a key challenge existsevidence suggests that SADC remains poorly equipped to initiate and manage the political discussions within and between member states that are required to develop appropriate regional responses to migration, mobility, and HIV [11,39]. This is partly due to the historical preference for the development of individual bilateral agreements between member states rather than regional responses [39]. However, as presented in Table 1, some regional processes have been initiated. For example, the SADC Framework for Population Mobility and Communicable Diseases was developed in 2009 [40] but remains in draft form with several member states refusing to ratify the Framework. The associated exercise to explore financing mechanismsat the request of member stateswas eventually completed by SADC in 2015, but remains unpublished (Oxford Policy Management, unpublished work). In 2010, the "SADC HIV and AIDS Cross Border Initiative" was awarded funding from the Global Fund to establish a regional cross-border HIV programme involving the establishment of 32 clinics offering HIV testing and treatment, alongside primary care, in border areas and along transit routes to serve migrant and mobile populations, and local migration-affected communities; 12 mainland member states signed Memorandums of Understanding (MoUs), agreeing to participate [41]. However, progress is painfully slow: phase 1 involved just 12 clinics being opened, and the second phasewith a further 20 clinics due to open was initiated at the end of 2017, with the anticipation that all 32 clinics will be handed over to member states in the first half of 2018. The slow process and challenges associated with this give a good indication of the challenges facedboth political and logisticalin developing and implementing crossborder, migration-aware HIV interventions at a regional level. The only regional health and migration policy process that has been implemented is the 2012 Declaration on Tuberculosis in the Mines [42]; ratification of this Declaration happened quickly, and appears to be the result of any associated financial burden being the responsibility of the private sector, and not member states who are unwilling to commit to regional responses associated with migration and health.

| A local lens: South Africa's engagement with migration and health
Within the SADC region, South Africa is the recipient of the largest number of cross-border migrants (most of whom come from other SADC states), has a long history of internal migration, and a continued high prevalence and incidence of HIV [11,13]. However, responses to HIV that engage with population mobility are noticeably absent, in spite of calls being made for migration-aware responses to HIV [10,12,43,44]. In addition, South Africa has not ratified the 2009 "Draft SADC Framework on Population Mobility and Communicable Diseases"in spite of the development of financing models to support equitable cost-sharing for regional responses to HIV. . In 2014, a task team was established to explore HIV, migration and mobility within the National Strategic Plan for HIV, STIs and TB. However, responses to migration in the national HIV plan remain limitedand no framework has been developed for their implementation [12]. South Africa is in the process of developing a National Health Insurance (NHI) whichin many waysis a progressive development. However, current iterations of the NHI present a possible regression in the rights of non-nationals to access healthcare, including ART [52].

| CONCLUSIONS
There is an urgent need to develop migration-aware [13] and mobility-competent [3] responses to health globally. Particular concerns are raised around the need to develop appropriate responses to migration and HIV in SADC. While gains have been made in the response to HIV in SADC, multiple challenges remainparticularly in the era of UTTas current responses do not adequately engage with migration and the movement of healthcare users [13,53]. HIV prevalence and incidence remain high, and it has been suggested elsewhere that it is the lack of migration-aware programming that has undermined HIV prevention efforts at the regional level, where diverse internal and cross-border population movements are prevalent [13]. Currently, public healthcare systems in the southern African region are not designed to ensure continuity of care for migrant and mobile populations and prevailing xenophobic and anti-foreigner sentiments present additional barriers to cross-border migrants [11,12,34]. The development of increasingly securitized migration management initiatives results in some crossborder migrants struggling to access the documentation required to be in a country legallywhich is often required to access healthcare [12]. As a result, people moving both within countries and across national borders face barriers when trying to access HIV prevention, treatment and care [12,53]. The established evidence is clear: delayed testing and/or treatment initiation has negative impacts for infected individuals and for the populations with which they interact [34]. By not engaging with migration, programmes currently designed to support HIV testing, antiretroviral treatment initiation and treatment continuity are jeopardized, with potentially, devastating consequences for HIV prevention programmingparticularly in relation to UTT initiatives.
Concerns about how the Global Compact processes may undermine efforts to improve responses to health and migration globally should not be taken lightly. Vigilance is required to ensure that migration-aware public health programming is not co-opted to support securitization agendas that place the health and wellbeing of people on the move at risk. Globally, contextually appropriate migration-aware responses to health are required; migration is a central public health imperative that provides a strategic opportunity to strengthen public health responses for allincluding universal healthcare coverage [10,12]. In the SADC context, HIV prevention and treatment programmes will continue to struggle if migration is not mainstreamed, and key health targets will not be met [12]. There is an urgent need to implement a regional strategy for the development of contextually appropriate migration-aware responses to HIV in SADC, particularly in the UTT era. Efforts must be made to ensure that local-level health programmingincluding HIV programming in SADCis not undermined by current global moral panics, and resultant policy discourses.

A U T H O R ' S A F F I L I A T I O N S
African Centre for Migration & Society, University of the Witwatersrand, Wits, South Africa; Centre of African Studies, University of Edinburgh, UK

C O M P E T I N G I N T E R E S T S
The author has no conflicts of interest to declare.

A C K N O W L E D G E M E N T S
The author thanks the Wellcome Trust for funding an Investigator Award held by the author (WT104868MA) that facilitated the research and writing of this article.